Newest of the New

No beating around the bush i'm just going to jump right into this one. Lets start with whats fresh in my head. This week I'm back at the military hospital (Hospital Militar). This is a private hospital for military personnel and their immediate family. I would say that its one of the better-supplied hospitals in Quito.

The last thing I want is for my blog is it to be a source that is fueling some kind of bad reputation for Ecuadorian surgeons, but I must be bad luck for Cholecystectomies even though I don't believe in luck. The reason I say this my first day back at Militar there were once again complications in an usually short laparoscopic procedure. I hate to beat this into the ground but I want to make it perfectly clear that these stories are written with no intent to disrespect any of the health professionals at Hospital Militar.

Above is the OR where most Cholelaps go down. This is while the surgeon is putting the four ports. This is the third different surgeon I have seen perform a Chole and its very intriguing to me how each surgeon has their own respective style. Like I commented before, one surgeon works between the patients legs, and the others to the patient's left. Every surgeon puts the camera port through the navel, but all other ports are respective to the surgeon. 

From the beginning the surgeon continually made comments about what a pain this specific gall bladder was and how he had never seen one like it. He commented several times on how the excess fat surrounding the gall bladder made the surgery very difficult "Una vesícula grasosa". 

While cutting the fat away from the Gall Bladder the surgeon accidentally made a small cut in the wall of the Gall Bladder. Right away bile started pouring out followed by many small gall stones. At this point the relaxed mood of the OR turned into a mix of frustration and hurry. Due to the location of the cut, the gall bladder essentially evacuated into the patient's abdominen. The surgeon wasted no time: he removed all the laparoscopic equipment and began making a large incision in the patients right upper quadrant, as shown above. One thing I found very surprising was how the surgeon called in another surgeon to help. From this  point it was pretty routine. 

Above is just before they stapled the gall bladder and cut it out. At this point the mood of the OR changed again back to the more relaxed, usual atmosphere. 

Here the surgeon is inspecting the gall bladder. Where his left thumb is marks where he accidentally cut.

I never took the time to count, but these are all the stones that leaked out. This doesn't include all the stones that were still in the gall bladder. In my amateur opinion, this seems like quite a bit of stones!!

While having the patient open, the doctors also discovered this. New to me, it is a case of Meckel's Diverticulum which is an usually asymptomatic deformation in the small intestine. 

Now i'm going to jump back to last week. Due to my unfortunate sickness the week before, I returned to Tierra Nueva in the Emergency room. This hospital is also called Padre Carolla, who was a priest in Quito. He started a foundation with the view of providing good, affordable healthcare apart from the public system. It is interesting that this particular has a lot of financial support from many international sources. According the doctors at Padre Carolla, this hospital falls somewhere in between public and private. It is open to the public but not free like public hospitals. Not to say that is not very affordable. A routine consult only costs a patient $4 and a normal birth costs $100. Unfortunately I don't have any pictures from Tierra Nueva so this section will be all words!!

The hospital is the second nicest and advanced one I have seen in Ecuador (please excuse my repetition if I have already talked about this). I only saw a few interesting cases while I was there, but I had the opportunity to spend a lot of time with several residents and interns and I learned a lot about some of the problems with the medicine in Ecuador. The first notable case I saw was a young girl who was having a heart attack. She suffered from antiphospholipid syndrome which from what I have found manifests as a very complicated syndrome so I not begin to try to explain for fear of giving false information!!

Another interesting case I saw was a 4-year-old boy who fell playing in the park. He hit his head on some metal part of the park structure and had quite a large laceration on his forehead. It stretched from below his left eyebrow across his forehead to his upper hairline. The cut was deep enough that you could see his skull. The kid was surprisingly calm, and I feel bad for him because he will always have quite the scar on his forehead. I asked the doctor about taking a CT and he said it wasn't necessary. Even though the kid displayed no signs cerebral damage it just seemed necessary to me, but thats simply my amateur opinion!

The one night shift I worked at Tierra Nueva was fairly slow. I worked from 8pm to 3am and the only case I saw apart from people with the flu was a highly intoxicated male who had fallen and cut his head. What was surprising to me was how this fairly small laceration was bleeding profusely. Blood was basically pouring out of his scalp, much more than the young boy with a cut four times the size. Maybe as punishment for being stupid and drunk but the doctor didn't bother with a lidocaine block, he just cleaned it up and sutured him up. This goes without saying but the man had a tough time dealing with the pain of getting his head stitched with no local anesthesia. He was heavily intoxicated however, so maybe he wont remember anything. After about 1am the ER really slowed down. I spent a lot of time talking to an intern about the problems Ecuador has in Medicine.

One major difference from the states is there are no "drug seekers" that come into the ER looking for drugs. Every patient that comes in is genuinely in need of help. According to the intern there is no problems with patients seeking narcotics due to a newly implemented system that makes it fairly difficult to get narcotics. I'm not entirely sure how this system works so I will have to get back to that. One problem she emphasized was antibiotic resistance. Due to careless administration of antibiotics there is a high prevalence of antibiotic resistance. According to her, doctors here have a tendency to give antibiotics that are much stronger than necessary, which has been leading to this problem. 

Another problem she touched on was inadequate ambulances. Apparently it is rare for medical professionals to be present in the ambulances. This also depends on the hospital, because each hospital also has their own ambulances (public vs. private). A lot of lives could be saved if this system were to change, but right now there is only one school in the entire country that teaches EMT-like courses. A sad example is how she lost her brother a few years back because he was having heart complications but the ambulance had no one with adequate knowledge to help him and by the time he arrived at the hospital he was in a vegetative state. 

I hate to end on a sad note but thats all I have for now. I'm back at Militar and i'm hoping to see some great surgeries this week because my time here is slowly slipping away!!

Back in Quito

Forgive me for my tardiness with updating my blog but I feel I have a valid excuse. I've been bed-ridden for the last three days and i'm finally starting to get better. I was down with a really bad fever with lots of joint pain, dizziness, headaches, and nights sweats. A bad cough and a sore throat put the icing on the cake. After a visit to the hospital yesterday and some magic shots (antibiotics) things are starting to look up. This seems like the worst place to get sick because right now its cold and raining (much like Oregon) but one can definitely feel the altitude on top of it all.

It was ironic being in the ER here, it was like a "student becomes the patient" experience.... I look at it all as part of the cultural experience. But enough about poor, poor, pitiful me, lets get to the good stuff.

After an initial two days of full-day classes I started back up rotations at Hospital Militar (try to say it with an ecuatorian accent). Above is the view from the eight floor looking north. Here I work with Dr. Vargas who is a GI surgeon. My first day here was a very eventful day. Within twenty minutes of being there we headed down to the OR. This hospital is much bigger than in Chone. I never got an accurate count but I saw around 10 ORs. I actually didn't get to see a surgery with Dr. Vargas this day (or any day for that matter) because he sent me to watch an aortic valve replacement. 

Getting to see this was a very rewarding experience. The surgeons were obviously very busy and not able to explain much but I was fortunate that there was an anesthesiologist who was very helpful. Initially I was every surprised how much human ribs can stretch apart with minimal damage. I was honestly almost more fascinated by the cardiopulmonary bypass pump than I was the actual surgery. It was very interesting to see the process of when they had the patient intubated and then switched to the 

CPB pump by using propofol to induce sleep. Then they packed around the heart with frozen saline solution to lower the heart's metabolic activity. It was surprising how at that point the heart could go over 3 minutes without any tissue damage. If I remember correctly they ran a line directly into the aorta, and one coming out of the Superior Vena Cava but don't quote me on that. They also ran a line to each coronary artery and would feed it every three minutes. 

No real justification for posting this picture other than I think its was a good picture. To the right closest to the patient is the chief cardiologist at Hospital Militar. Unfortunately I couldn't stay for the entire procedure. I left when they were suturing in the valve into the aorta. I would have liked to see how they brought him back and closed him up, but not this time!!

The next day at Militar was not quite as eventful as the first day's surgery but I learned a lot. The day started with rounds with Dr. Vargas. Almost every patient we saw were post-op cholecystectomies. I never got a chance to ask why gall stones have such a high prevalence here. It was fun to watch the Doc quiz all the interns and try to answer the questions myself (in my head). Dr. Vargas grilled one of the interns pretty hard about he thinks of medications first for a post-op patient, not wound care, vitals signs, physical exams... etc.  The day ended with a presentation the human bodies response to surgery. The doc had some great points that really hit home: Most people think of surgery as a benign process, but it is indeed a trauma. Its comparable to a car wreck or some other major wound, the only difference is with surgery you're asleep. Although you're asleep, the body still has a stressful response to a major trauma. For this reason they're pushing more and more towards less and less invasive procedures. The presentation went over all the different responses the body can have to the trauma of surgery like anxiety, pain (obviously), hemorrhaging, increased vasopressin levels, increased cortisol levels... etc. 

The third day at Militar started out routine but turned around quite quickly. I went straight to the OR (they call it Quirófono in Spanish) to see two cholys. I'm not sure if thats how you spell the abbreviated  cholecystectomy so forgive me!! The first surgery was a laparoscopic choly, as I believe all are at Militar. Everything was going to plan until the surgeon hit an artery. He was unable to stop the bleeding so they had to pull all the laparoscopic tools and switch to a full-open surgery. It was amazing to see how fast a surgeon can open someone up when the time calls for it. I want to make it clear that by writing this I mean no disrespect to this surgeon, the hospital, or any surgeon in Ecuador for that matter. Even surgeons are human and make mistakes and this was not due to carelessness but simply a mistake. From there the surgery went very smooth and the patient was fine. 

I watched a second laparoscopic choly. Basically identical minus the mishap, but it was interesting to watch how two different surgeons have their own styles. For example one surgeon worked from the patient's left side while the other worked by standing between the patient's legs. Due to their different positions they also made incisions in different places, and how they went about cutting and cauterizing the arteries feeding the gallbladder. 

This week I started in the ER with a resident at Tierra Nueva. By far the most advanced hospital I have seen here. Its brand new and is a very classy hospital. I was pushing it going to clinic that day and paid the price. I was pretty sick for all of the day and was unable to make it to class. I haven't been back since, but hopefully i'll be 100% ready to go back next week. 

Final Thoughts on Chone

Well i'm back in Quito now and I want to wrap things up with respect to Chone. I've adapted to the costal weather and i'm in the process of getting used to Quito again. In other words, I get winded walking up stairs and I'm not sweating all day like I was used to in Chone. A thought thats been marinating in my brain for the last few weeks that i've been dying to get out is what it means to be "Chonero".

First off, what is a Chonero?? If its not too obvious, a Chonero (or Chonera) is anyone from Chone. What is Chone?? Chone is a small town in the coastal region of Ecuador on the Chone river. As said by the doctor I worked with the last three weeks: "Chone es al cuidad de las naranjas, las mujeres hermosas, y los hombres celosos" (Chone is the city of Oranges, beautiful women, and jealous men). I couldn't agree more. Oranges are definitely a big deal in Chone (along with bananas) and the women in Chone are very beautiful.

Perfect example above of the beautiful women in Chone (Nurse Roxana and Secretary  Yajaira). But back to what it means to be Chonero. I can't help but draw a parallel between Choneros and the stereotypical American Redneck (no disrespect to the Chonero). What I mean by this is that Choneros are a very hard working group and they're very proud of how hard they work and they're very proud to be from Chone. When you ask them where they're from they always answer "cien porcento chonero". Thats about where the parallel ends. Choneros are some of the nicest, outgoing people I have met in Ecuador. Everyone knows everyone, and they love to stop me on the street just to ask how my day is going, where i'm from, and what i'm doing in Chone. My last week in Chone i'm pretty sure I was the only white person within a ten mile radius, so I got stared at on a constant basis, but after a while I became immune to it. 

In comparison to other regions of Ecuador, Choneros have a very relaxed lifestyle and consider themselves much different than other Ecuadorians. Those who live in Chone work hard and live life to its fullest (sounds so cliché, but these are direct Chonero words). When they get up, they get up, "cuando se levanta, se levanta". They believe this lifestyle is better for the health and in no way do I disagree. They work hard all day, and then relax in the afternoon and night. Most of this is coming from a lengthy conversation I had with a man in the hospital in Chone whose daughter was recovering from surgery. He talked about the country and everything out there was better than the city. The chickens range free of fences and chemicals. He went on about how the fruit grows bigger and tastes better. It was a great experience to see someone so passionate and proud of something so simple. By "United States Standards" Choneros have next to nothing but they are some of the happiest, most content people I have had the pleasure to meet. Its nice to see how happy someone can be without the nicest car, the biggest house, and the fanciest toys. 

Above is my Chone family. Pepe is a perfect example of 100% Chonero. He was a taxi driver in Chone for 30 years and makes for some great conversations during dinner. I'm not sure if he meant to but he never failed to make me laugh everyday. Mariana is a great cook and taught me some great ways to cook up bananas. I have to give her a shout out now for the great food, hospitality, and hand-washed/hang-dryed clothes. Theres only one thing I wont miss about Chone, which is the damn bug bites. I don't know how, but they always seemed to find me and eat up legs and feet!!

Cristina is another member of the family. Quite possibly the cutest 5 year old girl on this planet. She speaks better spanish than I do, and loved to make faces at me while I was eating dinner. I wish I could adopt her but I doubt her dad would go for that. 

This was part of the Pediatric crew I worked with every morning. Everyone was great in Pediatrics. They were always willing to teach and very easy to get along with. Right behind me is Dra. Díaz who makes the whole program in Chone possible. She is a great doctor and a great teacher. She, along with Dra. Tejado to her left, are great people and respected members of Chone. I spent a lot of time with Dra. Díaz at the hospital, in consults, and we spent some good time translating WHO guidelines for Dengue Fever that were in english. Now I consider myself a Dengue Fever expert. 

This is Dr. Vera and Dr. Robosky (left to right) orthopedic/trauma surgeons. I spent a lot of time with these guys. I got to see everything from amputations, to compound fractures, to repairing tendons. Not only are they great Docs, but quite the characters too. They're pretty funny guys. They were really great about teaching and keeping me involved during the surgeries. I won't lie, they were difficult to understand and at first very intimidating (not on purpose). 

This is an example of one of the many surgeries I got to see with Dr. Vera and Robosky. Coming from a construction background its funny how much Orthopedic surgery is just like construction, just much more meticulous. 

Time to Update

I have elected to not update during the week in Chone. Spanish keyboards are a pain, and its too much work to upload pics without a jump-drive. I figure its easiest to start out with whatever first comes to mind... which is surgery. The two Docs I shadow are orthopedic/trauma surgeons: Dr. Vera and Dr. Robosky. Both are great surgeons and always work together... not sure how common that is amongst orthopedic surgeons. They work Tuesday and Thursday and it is one of the highlights of my week.

The latest surgery I saw as the amputation of a man's left leg. He was diabetic and cut his foot on the inside of the his heel. He didn't take care of it and he was admitted the day before surgery with some pretty bad necrosis. The tissue had died in an area about four square inches on the inside of his foot. As one can imagine the amputation was pretty gruesome. They just did local anesthesia to block him from the waist down... the poor guy was conscious for the amputation of his left leg. They started by just cutting skin with a scalpel, then used cautery to cut pretty much everything else. The docs showed us the sciatic nerve and also put my finger on one of the major arteries (I was scrubbed in), which was cool too feel/see an artery directly. They cut his leg about mid-femur. When they got to the bone they used a file that looked like a rope with two T-handles on both sides and see-sawed right through the femur like it was nothing. The patient kept picking his head up and looking, and the surgeons kept telling him to stop... not sure what I'd do in his situation. Then they sewed him up and it was only about a 30 min procedure not including anesthesia. 

The above picture is of the OR. I believe there are five total, I haven't seen them all. The fore-mentioned surgery was this last thursday. Tuesday we had two patients. The first was a 9 year old girl who cut the top of her foot and needed to top tendons/muscles on her foot sewn back together (it was a lot like the machete wound, but the foot). The second surgery was a young boy who broke his radius and ulna playing soccer. It was pretty bad break, both bones were broken completely in half. They put a rod in the radius and a plate with five screws in the ulna.

Above is the public hospital in Chone where I work: Hosptial Napoleon Davila Cordova. Its the only public hospital in the city and within a two hour bus ride for that matter. The hospital sees mainly people from Chone and the "campo" outside of the city, but its public and open to anyone. There's also a social security hospital in the city that is private. The pediatric ward can hold 40 patients as with the floor above (internal med). All hospital employees are government employees and all the care provided is free to Ecuadorian citizens (paid by the Ministerio de Salud Público). I still start every day with pediatric rounds with Dr. Díaz and then depending on the day I end up somewhere else (tuesdays and thursdays are surgery days). Friday we did a tour of the Neonatal ward in the hospital. There was one baby boy who was born premature (27 weeks 4 days). It was pretty sad/incredible to see the little guy on a ventilator. Everyone was kind of on their toes not knowing if he was going to make it. Today the word was he was doing well and his O2 sats were good off the ventilator. However, I don't believe Chone has an MRI so theres really no way to tell if he has brain damage. The rest of Neonatal was mostly newborns with colds or fevers.

100% Chonero

Lets talk Chone. The name says it all. Chone is Quechua for "Inferno" and yes, its VERY hot. My host family tells me that this is actually the colder time of the year. The rainy season from January to April-ish is much hotter. Its plenty hot for me. Just doing rounds in the morning and walking home after clinics I am dripping with sweat. There's no such thing as hot showers, and it would seem relatively pointless anyway. My family in Chone is great. Mariana and Pepe are "mom and dad" and their son Javier has a small family practice that he runs out of the house. Mariana's son-in-law, also named Javier lives "junto" to their house, so pretty much the same house. Mariana is a great cook and very helpful.


Since this is an urban/rural comparison program, lets compare. So far I have seen only two hospitals in Quito. La maternidad is not what I would consider an advanced hospital, but i've heard good things about other private hospitals that are pretty nice. Axis, which i've only been in non-clinical, is very nice and it looks brand new inside. The public hospital in Chone is not the fanciest hospital in the world. Its probably the tallest building in the town, the concrete is cracking, and they're undersupplied. One of the best things i've noticed about comparing the two cities is regardless of what the hospital looks like, the personnel are extremely smart and caring. The doctor who leads the Chone part of my program, Dr. Díaz, is a pediatrician and is one of the best doctors I have shadowed. She is incredibly smart, caring, and somehow makes every one of her patients and their parents smile, laugh, and love her. She is a great teacher and takes time to make sure we understand everything. One of my favorite things about working in Chone is not a single patient, doctor, nurse, or intern speaks english. At some times it seems like they're speaking two foreign medicines (spanish and medicine).

We start every morning with Pediatric rounds, which are very interesting watch. Tuesday and thursday we had surgery. Yesterday (thursday) was a great day for surgery. The first patient had been attacked with a machete, and used his left forearm to block the blade. It cut most of his extensor muscles. The docs first tried to block his whole left arm with lidocaine, but he could still feel it, so they had to knock him out. It was really cool to see them checking with muscles went where because they could pull on a tendon and his fingers would move. They made a pretty large incision in his arm and sutured the tendons and muscles back together, and the surgery was a success!!
The next one we saw was pretty gruesome. A man had fractured his his Tibia and had a plate put in. The plate became infected and they had to remove it. A very large incision was used to open it up. Upon removing the plate the docs discovered that two of the screws had broken inside the bone. They spent a fair amount of time removing them. The poor guy was concious the entire time, they just blocked him with lidocaine from the waist down. It must have been pretty tough for him to listen to the scraping, drilling, and cutting of infected bone. It was pretty crazy to watch the block being put in his spine... lesson: Don't break your leg!!!!!

Internet is expensive and charged by the hour here and i'm being cut off.... thats all for now, i'll post some pics tomorrow.
Adios!!

Pre-Chone

Well I finally found WIFI... not in Chone however. Part of the Quito group met Sam and I at a small Costal town on the southern part of Ecuador called Montañita. Its a pretty touristy type town but its still pretty laid back and I can still find my $2 lunches. The people here are pretty mellow and are always down to stop and chat in Spanish. Surprisingly there is a large population of northern Europeans here. The water is warm, the food is good, everything is cheap, and you can get an ocean-front hostel for $10 a person for per night. So if you can picture where i'm at in your head: Small internet café on a small quiet street, Ecuadorian music playing in the background, fresh fruit and fish vendors cruising by on their bikes, and the smell of food and ocean which is three hundred feet away.

I want to go back and touch on the Pichincha volcano climb. The climb starts at the top of the gondola which seems like cheating but it would take all day without it. The summit is 15, 413 with is a small rocky top. At 15,000 feet the concentration of oxygen is only 55%. It climb itself looks less than intimidating but the lack of oxygen makes it incredibly difficult. Toward the top we could only go for about a minute without stopping. It was a very humbling experience, I was really surprised how long it would take me to catch my breath. I'm really leaning towards climbing Cotopaxi, so i'll have to do it again after spending three weeks in Chone. The picture above is me reppin' OSU over 15000 feet up in the middle of the world!!

I know I know, this is so cliché especially because I bring my Powered by Orange shirt everywhere, but its just one of things you "can't not" do when you're that close to the equator. Its not that exciting there apart from the fact that you can stand on two different hemispheres, which is pretty cool, but theres really nothing else to do there unless you want to pay for cheesy tourist trinkets or weigh yourself on the equator for 50 cents..... Bob Marley just came on.... peeeerrrrfect!!!

Latest and Greatest

well this will be short and sweet. im now in chone, which is definitely more rural than quito. the only internet access i can find is a little shop in the center of town where you cannot use your own computer... needless to say the keyboards have a different layout and are kinda confusing, plus i cant post any pictures. last saturday the quito group climbed pinchincha, which is a mountain to the east of quito. a gondola takes you part of the way, but the rest is a pretty difficult but rewarding climb. it goes up to over 14000 feet so its pretty difficult to breathe. the clouds rolled in before we got to the top which was a bummer but it was still pretty cool. my first clinic day was pretty interesting. the main doctor i work with does pediatrics, so sam and i did rounds which was pretty fun, and then did some routine check ups in her office. today was great. we had two sugeries that we scrubbed in for. the first was removal of a sinovial cyst and the second was removing some metal rods from a guys leg. the first surgery i got to hold the skin back with some utensil, i don´t know the english name for it. after removing the cyst the surgeon let me finish the suture which was incredible. im glad i had practiced, but i was still nervous and my hands were shaking haha, but i did a good job. im hoping for another shot at it soon. we have surgery again thursday. thats all for now. i´m hoping to find a place with wireless so i can use my laptop`but we´ll see.